Rosen & Barkin's 5-Minute Emergency Medicine Consult (561 page)

• Indications: Arsenic, copper, lead, mercury with/following BAL or EDTA
  
• Warnings: Contraindicated in penicillin allergy, renal insufficiency
  
• Dose:
  
  • Lead:
    
    • Adult: 250–500 mg per dose PO q8–12h
      
    • Pediatric: 25–40 mg/kg/d PO in 3 div. doses
      
  • Arsenic: 100 mg/kg/d PO div. in 4 doses for 5 days (max. 1 g/d)
    
  • Mercury:
    
    • Adult: 250 mg PO QID
      
    • Pediatric: 20–30 mg/kg/d PO in 4 div. doses
      

• Indications:
  
  • Hypertensive crisis: Stimulants, sympathomimetics, MAO–tyramine reaction, and extravasated pressors
    
  • Reversal of cocaine-mediated vasospasm
    
• Warnings: HTN, tachycardia, dysrhythmias
  
• Dose:
  
  • HTN (HTN):
    
    • Adult: 1–5 mg IV bolus
      
    • Pediatric: 0.02–0.1 mg/kg bolus
      
  • Extravasation:
    
    • Adult: 5 mg diluted in 10–15 mL saline SC
      
    • Pediatric: 0.1 mg/kg diluted in 10–15 mL saline SC
      

• Indications: Severe anticholinergic syndrome
  
• Warnings: Contraindicated in TCA overdose
  
• Dose:
  
  • Adult: 0.5–1 mg IV, repeat in 10 min PRN
    
  • Pediatric: 0.02 mg/kg IV, repeat in 10 min PRN
    

• Indications:
  
  • Organophosphate toxicity
    
  • Reversal of nicotinic effects
    
  • Reactivates enzyme
    
  • Use in conjunction with atropine
    
• Warnings:
  
  • Myasthenic crisis if myasthenia gravis
    
  • Nausea, headache, dizziness, laryngospasm, muscle rigidity
    
• Dose:
  
  • Adult: 1–2 g IV in 100 mL NaCl over 15 min, repeat in 1 hr PRN, repeat in 6 hr if nicotinic symptoms return
    
  • Pediatrics: 25–50 mg/kg over 15 min, repeat in 1 hr PRN, repeat in 6 hr if nicotinic symptoms return
    

• Indications: Reversal of heparin anticoagulation
  
• Warnings:
  
  • Hypersensitivity in patients with fish allergy
    
  • Avoid benzyl alcohol diluent in neonates.
    
• Dose: 1 mg for each 100 IU heparin, 1/2 dose if 30–60 min; 1/4 dose if 2 hr after heparin bolus;
  
  • 25–50 mg slow IV over 15 min. Initial dose should not be >50 mg
    

• Indications:
  
  • Isoniazid-induced seizures
    
  • Gyromitra
    mushroom
    
• Warnings: None, nontoxic
  
• Dose:
  
  • Isonicotinic acid hydrazide (INH)–induced seizures:
    
    • Unknown ingested amount: 5 g for adult or 1 g for pediatrics
      
    • Dose (mg) = amount INH ingested (mg)
      
    • Gyromitra
      : 25 mg/kg IV over 30 min–1 hr
      

• Indications: Significant envenomation by
  Crotaline
  species: Rattlesnake, cottonmouth, water moccasin, pit viper
  
• Warnings:
  
  • Ovine-derived products: Immediate hypersensitivity, serum sickness 10–14 days
    
  • Premedicate for anaphylaxis if we know the equine/ovine serum hypersensitivity.
    
• Dose:
  
• Ovine derived (CroFab):
  
  • 4–6 vials slowly; may repeat dose of 4–6 vials if control of envenomation not achieved, then 2 vials q6h for 3 doses
    
  • Reconstitute each vial with 25 mL sterile water. Dilute in 250 mL 0.9% NaCl and infuse over 1 hr.
    

• Indications: Reversal of Coumadin anticoagulation
  
• Warnings: Hypersensitivity from IV administration
  
• Dose:
  
  • 2–10 mg SC/slow IV, may repeat in 8 hr
    
  • 2–10 mg PO, may repeat in 12–48 hr
    

CODES

977.9 Poisoning by unspecified drug or medicinal substance

BASICS

Modalities to decontaminate the GI tract of poisons

TREATMENT

• Airway, breathing, and circulation management (ABCs):
  
  • Secure airway for decreased mental status/inability to protect airway.
    
  • IV access
    
  • Cardiac monitor
    
• With altered mental status from overdose:
  
  • Naloxone
    
  • Thiamine
    
  • Dextrose (or Accu-Chek)
    

• Activated charcoal:
  
  • General:
    
    • Prepared by treating heated wood pulp, which creates a large surface area to bind toxins
      
    • Mainstay of gastric decontamination
      
    • Effective when contents have reached small intestine
      
  • Dose:
    
    • 1–2 g/kg of body weight or an activated charcoal-to-drug ratio of 10:1; often mixed with sorbitol (see below)
      
    • Oral or nasogastric tube administration
      
  • Indications:
    
    • Administer in every toxic ingestion (see below for exceptions).
      
    • Optimal for toxic ingestions presenting within 1 hr of ingesting a drug that is absorbed by charcoal in a patient with a patent airway
      
  • Adverse effects:
    
    • Vomiting and constipation
      
    • Charcoal aspiration and subsequent charcoal pneumonitis
      
  • Contraindications:
    
    • Caustic ingestions
      
    • Unprotected airway
      
    • Bowel obstruction or ileus
      
  • Drugs not effectively bound to charcoal:
    
    • Metals (borates, bromide, iron, lithium)
      
    • Alcohols
      
    • Potassium
      
    • Potassium cyanide (poorly absorbed)
      
    • Hydrocarbons
      
    • Caustics
      
  • Pediatric considerations:
    
    • Mix with palatable substance (cola or juice) to facilitate intake or administer via gastric tube.
      
  • Controversies:
    
    • Randomized, controlled trials have shown a slightly worse outcome and higher complication rate when
      asymptomatic
      patients received charcoal vs. nothing.
      
    • An extremely small minority of patients are likely to benefit from gastric lavage.
      
• Multiple-dose activated charcoal:
  
  • General:
    
    • Used in toxic ingestions that are well absorbed by charcoal and undergo enterohepatic circulation
      
  • Dose:
    
    • 1 g/kg followed by 0.5 g/kg q2–6h
      
    • Never use cathartics in conjunction with multiple-dose activated charcoal.
      
  • Indications:
    
    • Salicylates
      
    • Theophylline
      
    • Multiple-dose activated charcoal may decrease area under the curve for drugs such as phenobarbital, phenytoin, and carbamazepine but has not been proven to improve outcome.
      
• Cathartics:
  
  • General:
    
    • Used in combination with activated charcoal to prevent constipation and to enhance GI transit time
      
    • Limited data available to demonstrate any decreased absorption when a cathartic (sorbitol) is added to activated charcoal
      
    • Cathartics alone are of no proven benefit and should be avoided.
      
    • Never
      use cathartics in conjunction with multiple-dose activated charcoal.
      
  • Dose:
    
    • Magnesium citrate: 10% solution: 250 mL (peds: 4 mL/kg)
      
    • Magnesium sulfate: 15–20 g (peds: 250 mg/kg)
      
    • Sorbitol: 0.5–1 g/kg to a max. 100 g of 70% solution (peds: >1 yr old: 0.5–1 g/kg as a 35% solution to a max. 50 g) PO mixed in the activated charcoal slurry—use only in 1st dose.
      
  • Adverse effects:
    
    • Dehydration
      
    • Hypermagnesemia
      
    • Diarrhea
      
    • Abdominal discomfort
      
  • Contraindications:
    
    • Pre-existing dehydration
      
    • Renal disease (cathartics containing magnesium)
      
    • Avoid in children
      
  • Controversies:
    
    • No proven benefit and some cases of harm reported
      
• Whole-bowel irrigation:
  
  • General: Cleansing of bowel
    
  • Indications:
    
    • Toxins not well absorbed by charcoal, such as toxic iron and lithium ingestions
      
    • Toxins in sealed containers (body packers) without signs of GI perforation
      
    • Toxic, sustained-release product ingestions
      
  • Dose:
    
    • Polyethylene glycol (Colyte, GoLytely)
      
    • Solution at 2 L/hr in adults (0.5 L/hr in children) until rectal excretions clear
      
    • Administer via nasogastric tube with activated charcoal via continuous or bolus method as indicated.
      
  • Adverse effects:
    
    • Bloating
      
    • Rectal irritation
      
    • Frequent bowel movements
      
  • Contraindications:
    
    • Mechanical or pharmacologic ileus
      
    • Bowel obstruction
      
    • Hypotension
      
    • Intestinal perforation
      
    • Unprotected airway
      
• Orogastric lavage:
  
  • General:
    
    • Placement of large-bore tube (32F–36F) in stomach for removal of ingested toxins
      
    • Effectiveness of orogastric lavage depends on time since ingestion, timing of last meal, and toxin ingested.
      
    • Protected airway is essential prior to any attempts at orogastric lavage.
      
  • Indications:
    
    • Currently, rarely performed
      
    • Presentation within 1 hr of taking a potentially lethal ingestion with no known antidote
      
    • Poisoned intubated patient arriving within ∼1 hr
      
  • Adverse effects:
    
    • Intubation of respiratory tree
      
    • Esophageal or gastric perforation
      
    • Charcoal aspiration
      
    • Patient discomfort
      
  • Contraindications:
    
    • Large pills (limited by lavage-tube port size) ingestion
      
    • Caustics (acids and alkali) ingestion
      
    • Hydrocarbon ingestion
      
    • Ingestion of agents that rapidly depress mental status
      
    • Unprotected airway
      
  • Pediatric considerations:
    
    • Avoid in children
      
    • Unlikely to result in any clinically significant pill extraction secondary to smaller-bore orogastric tube (i.e., 18F)
      
    • Risk of aspiration increased in children
      
    • Controversies: Several randomized, controlled trials have documented no benefit when lavage plus activated charcoal is compared with activated charcoal alone.
      
• Ipecac:
  
  • General:
    
    • Rarely used
      
    • Derived from the roots of the plant
      Cephaelis acuminata
      
    • Exerts emetic action by direct gastric irritation and centrally mediated chemoreceptive trigger-zone stimulation
      
    • Delays administration of activated charcoal
      
    • Offers no advantage over activated charcoal alone when both treatments are potentially effective
      
  • Dosage:
    
    • >12 yr: 30 mL
      
    • 1–12 yr: 15 mL
      
    • 6 mo–1 yr: 5–10 mL + 15 mL clear fluid
      
  • Indications:
    
    • No utility in ED
      
  • Adverse effects:
    
    • Vomiting may complicate and worsen clinical presentation.
      
    • Delay to administration of activated charcoal or oral antidotes
      
  • Contraindications:
    
    • Caustics (acids and alkali) ingestion
      
    • Hydrocarbon ingestion
      
    • Ingestion of agents that rapidly depress mental status
      
    • Patient actively vomiting